Upper Abdomen and Multi-site Ultrasound Examinations... No Insurance Coverage Without Medical Evidence

by Byun Seonjin

Published 27 Apr.2023 17:41(KST)

Mr. A underwent ultrasound scans of five areas (upper abdomen, bladder, female reproductive organs, breast, thyroid) in one day due to abdominal discomfort and thyroid nodules. This was because all were covered by health insurance benefits.

However, going forward, to receive insurance coverage for multiple ultrasound examinations on the same day like Mr. A, medical justification for the necessity of each area’s examination must be confirmed in medical records before the test. Until now, there were no separate benefit criteria for multi-area ultrasounds, so insurance coverage was applied without limitation even when multiple areas were scanned on the same date.

On the 27th, the Ministry of Health and Welfare held the 7th Health Insurance Policy Deliberation Committee (HIPDC) meeting and finalized the “Benefit Criteria and Review Improvement Measures for Appropriate Ultrasound Examinations.” This is a follow-up measure to the “Measures to Enhance the Sustainability of Health Insurance” reported at the 3rd HIPDC held in February. Problems such as billing for ultrasounds without medical necessity by adding unnecessary tests were pointed out, raising the need for benefit criteria and review improvements.

Park Min-su, the 2nd Vice Minister of Health and Welfare, is presiding over the Health Insurance Policy Deliberation Committee meeting on the 27th.
[Photo by Ministry of Health and Welfare]

Additionally, ultrasound examinations of the upper abdomen for preoperative risk assessment will only be covered when upper abdominal disease is suspected. For example, reasons for suspicion such as abnormal liver function blood test results or the patient’s medical history must be recorded in the medical records before the examination. Currently, insurance coverage is applied even when upper abdominal ultrasounds are performed preoperatively for reasons other than upper abdominal disease. Because of this, 86% of preoperative upper abdominal ultrasound examinations are for surgeries unrelated to upper abdominal disease.

Based on the newly established benefit criteria, intensive and specialized reviews will be strengthened for medical institutions showing problematic testing tendencies without medical justification. A Ministry of Health and Welfare official stated, “Through this, we expect to block factors causing health insurance financial leakage and improve some indiscriminate testing behaviors, contributing to the establishment of a culture of appropriate medical care.” The ultrasound benefit criteria improvement plan will be implemented through revisions to the notification of standards for medical benefits application in the first half of this year after administrative notice. Furthermore, the Ministry plans to report and revise related notifications on the “Benefit Criteria and Review Improvement Measures for Brain and Head and Neck Magnetic Resonance Imaging (MRI),” currently under discussion by the benefit criteria improvement consultative group, within the first half of this year at the HIPDC.